An intense policy
debate is occurring in many countries on the legitimacy of laws ordering
people with mental disorder to accept outpatient mental
health treatment. Much of this debate on “outpatient commitment” assumes
that court-ordered treatment in the community is simply an extension
of long-existing policies authorizing involuntary commitment as a hospital
inpatient. In fact, however, outpatient commitment is only one of a growing
array of legal tools used to mandate adherence to mental health treatment
in community settings.

People with severe and chronic mental disorders are often dependent
upon goods and services provided by the social welfare system. Benefits
disbursed by money managers and the provision of subsidized
housing have
both been used as leverage to assure treatment adherence in the community.
Similarly, many people with mental disorder become involved with one
or another aspect of the judicial system. For people who commit a criminal
offense, adherence to mental health treatment may be made a condition
of probation. Favorable disposition of their cases by a newly-created
mental health court may also be tied to treatment participation. In addition,
under some outpatient commitment statutes, judges have the authority
to order committed patients to comply with prescribed treatment in the
community, even if the patient does not meet the usual legal standards
for treatment in a hospital.

In response, a patient may attempt to maximize his or her own control
over treatment in the event of later deterioration by executing an advance
directive that specifies treatment preferences or a proxy decision maker.

The Research
Network on Mandated Community Treatment, funded by the John D. And
Catherine
T. MacArthur Foundation, seeks to elaborate a new
and broader conceptual framework to encompass all forms of mandated treatment.
To evaluate the role that mandated treatment may play in mental health
law and policy, we are engaged in conducting new research on how frequently
different types of leverage are used, how the process of applying leverage
operates, and what the outcomes of leveraged treatment are–for
the individual, for the mental health system, and for society. We are
also sharpening our understanding of the profound legal, ethical, and
political issues raised whenever leverage is used to secure treatment
adherence. If mental health law and policy are to incorporate–or
to repudiate–some or all of these types of leverage in the community,
an evidence-based approach must become an integral part of these deliberations.